HomeMy Public PortalAbout9363 LOWER AZUSA RD_Swimming Pool__ WORKERS'COMPENSATION DECLARATION •' s 7�
I her0b affirm that I have a certificate of consent to self
y
insure, egr'-n certiitcate of Workers'Compensation Insurance, APPLICATION FOR COMBINATION SWIMMING POOL PERMIT
or a cerfified copy thereof(Sec. 38r-,42b. C.) 76A20e
Policy Not Company CE876(3/84) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN BUILDING
Certified copy is filed with the county building inspec- ADDRESS
tion department. BUILDINGLA
•^ ADDRESS . LOCALITY F
Date pplicant NEAREST
CERTIFICATE OF EXEMPTIO FRO WORKERS' CITY ZIP CROSS R
COMPENSATION 1 NCE SIZE OF ASSESSOR
TRACT LOT LOT NO. MAP BOOK PAGE PARCEL
(This section need not be completed If the permit is for one TEL. / USE ZONE MAP
hundred dollars($100)or less.) OWNER Nt 72 NO.
I certify that in the performance of the work for which this SPECIAL
permit is issued, I shall not employ any person in any manner ADDRESS Q CONDITIONS
so as to become subject to the Workers'Compensation Laws. / DISTRICT STATISTICAL CLASS TYPE PROCESSED BY
CITY `_Q C` ZIP O. CONST.
Date Applicant ARCHITECT OR TEL. r CLASS N
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER O. 00
Exemption, you should become subject to the Workers' VALUATION
Compensation provisions of the Labor Code, you must forth- ADDRESS VALIDATION
with comply with such provisions or this permit shall be Cs o 'oo Q
deemed revoked. CONTRACTOR / NO.
LICENSED CONTRACTORS DECLARATION LIC'
ADDRE � NO � (� t
1 hereby affirm that I am licensed under provisions of Chapter 9 $ y
(commencing with Section 7000) of Division 3 of the Business CITY t,k-A:- CLALIC.55 CC s4
and Professions Code,and my Ii c se is in full force and effect. -+,r , 1�
�-�� DESCRIPTION OF WORK FINAL xS +-1 07 :7"�='
License Number Lic. Class SWIMMING POQ{,*� y/4/v 'lam DATE
pZ 4'D�GA P
Contracto e — SPA �slp9� FINAL ACCT. V
SQ. FT. BY %;. .
1 am exempt under Sec. SIZE -_-31137 %;
B.&P.C. for this reason ELECTRICAL 2E.
IT :9
Signature
Si nature Date. Steel &Conduit Bonding (IJ!i . 'c 42 o 2
9 Conduits, Conductors, Equipment 11 N
SINGLE FAMILY CHECK ``42.4iz
HOME OWNER-BUILDER DECLARATION PLUMBING ® (:MANGE ,0
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and P-Trap2.�ZL
r� .
Professions Code): Gas System [I(,l)_0—,100,91 1C1/15/9LD
1.
, as owner of the property, will do the plumbingand Anti-Syphon electrical work. I,or my employees with ages atheir yp x,510 1 AM11;o 21
sole compensation,or a licensed contractor will do all MECHANICAL
other work and the structure is not intended or offered
for sale (Section 7044 B&P Code). Swimming Pool Heater NA*
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for APPLICANT TE
the performance of the work for which this permit is issued (PRINT) NO
(Sec. 3097, Civ. C.).
Lender's Name ADDRES
Lender's Address
P.C. Fee$ Permit Fee
1 certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws relating to building, electrical, Issuance Fee J
mechanical and plumbing construction,and hereby authorize Investigation Fee
representatives of this County to enter upon the above- Total Fee
mentioned property for inspection purposes.
LO--15 b
S' atur of Applicant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE